How the Federal Vaccine Mandate Could Impact Nursing Homes

On August 18, the current administration announced a new mandate that would withhold Medicare and Medicaid funding from nursing homes whose staff are not fully vaccinated against COVID-19. The Centers for Medicare & Medicaid Services (CMS) is expected to deliver specific requirements in the coming weeks.

In the interim, many health care professionals and facilities are concerned that a federal mandate could threaten staffing in already pressured areas, leading to further challenges.

According to CMS data (as of August 8), 62% of nursing home staff across the country are vaccinated. At the state level, the number ranges from 44% in Florida to 88% in Puerto Rico. President Biden said the mandate is intended “to ensure we reduce…risks to our most vulnerable seniors.”

We turned to Ilene Warner-Maron, PHD, RN-BC-CWCN, NHA, president, Alden Geriatric Consultants, Inc, and Richard Stefanacci, DO, MGH, MBA, AGSF, CMD, senior physician, Trinity Health PACE, for insight into potential benefits and consequences of the COVID-19 vaccine mandate for nursing home staff, administration, and residents.

What are some key considerations for nursing home staff and administration to keep in mind under the vaccine mandate?

Dr Warner-Maron: With President Biden's announcement that federal funds will be withheld from nursing homes, it is now causing the nursing homes’ administration to step up and say, "What do we need to do differently?"

At least 40% of the nursing home workforce remains unvaccinated. If 40% of our staff are not going to be able to work, who is going to do that work? There has always been a problem with getting sufficient numbers of trained staff, and COVID-19 made that even worse.

We have always advocated that if you know that your census is going to be low, do not schedule staff, certainly not agency staff. Give people days off or vacation days. If you do that, and most facilities do, then you must do the opposite—if you know that your staffing is going to be low, you have to self-impose a ban on admissions because you cannot risk the health and welfare of the people that you already have in the building.

I think that there is going to be a lot of administrative pressure back up to the governing body saying, "We are not going to be able to maintain the target census that you are expecting from us because we do not have that kind of staff."

Dr Stefanacci: Remember the Triple Aim moved to the Quadruple Aim with the addition of reducing caregiver burnout. One group especially hit with burnout is our certified nursing assistants (CNAs), many of whom are among the unvaccinated, as they are fearful for many reasons about getting the vaccine.

Do not assume staff will comply rather than quit. If one assumes that staff will follow the mandate, one will be surprised by the number of staff that simply quits.

Do you think the mandate will impact certain states or demographics more?

Dr Warner-Maron: New Jersey has already passed this mandate long before President Biden. Different groups, like LeadingAge and the American Health Care Association, have already tried to put in these mandates.

Individual nursing home chains have been moving toward this—Genesis was one of the first, certainly the largest. They have a lot of nursing homes, and they have always had staffing issues. I do not know how they are going to manage it.

I suppose at some point it will have to result in a contraction of the census.

Dr Stefanacci: Absolutely. The states with lowest vaccination rates, whose employees make up populations most likely to be unvaccinated and most difficult to convince to vaccinate, will be hurt most. I am surprised no one has yet raised the issue of discrimination with this mandate, as it will impact certain groups much more than others, and the impact is potential unemployment, which is significant.

How can administrators approach implementing the mandate in such a way to ensure staff gets vaccinated and the nursing home does not lose funding?

Dr Warner-Maron: Before the mandate went into effect, we tried to focus on carrots rather than sticks, sticks being the mandate and carrots being why each individual staff member is reluctant to get vaccinated.

The concerns that people have expressed include, "I'm worried about my fertility. I'm worried that it is not FDA approved. I'm worried because I'm a minority and people have been experimenting on my people since time began."

You try to address these individual concerns that people have. You try to bring an OB/GYN into the facility to talk to the staff about what their concerns are; give them the most realistic, vital information; and show them that what they are reading about on Facebook is not necessarily accepted science.

Dr Stefanacci: People want to hear from their peers. The CNAs do not necessarily want to hear from me, but they want to hear from a community leader, someone that they respect.

Rather than have the medical director or administrator say, “This is the new mandate,” which is probably going to result in staff doing the opposite, there is an opportunity to tap into those peers in the community. Bring them in to educate the CNAs and others, so that we can increase the vaccination rate.

If the mandate is upheld, what do you think nursing homes will look like in the near future?

Dr Warner-Maron: I think that they will be smaller. Some of the research about COVID-19 said that the way to survive COVID-19 in a nursing home is to be in a small nursing home with small numbers of people.

Some of the other research has shown that having a lot of part-time employees can be more harmful for COVID-19 exposure because those part-time employees are working at multiple facilities. Nursing homes will need to put more emphasis on long-term employees, to make sure that they are getting the kind of support and financial resources that they need.

I think that nursing homes are going to have to be mindful of balancing staffing and that census in a way that they have never felt compelled to. We see facilities that have taken many admissions, even though they did not have enough staff, because they felt so pressured from the governing body. I think that is not going to be the case going forward.

Dr Stefanacci: Just look at the groups being vaccinated. When you look at the KFF numbers, which are consistent with other data, certain minorities are extremely under vaccinated. We will see greater numbers of staff from groups that are getting vaccinated and fewer numbers from groups that are not.

They are the ones who are front-line workers in nursing homes. If we make it mandatory and they quit, what are we going to do for staffing? Talk about adverse consequences: not only do we lose them, but now they become unemployed.

Do you think that there are any suitable alternatives to mandatory vaccinations that would keep residents and staff safe?

Dr Warner-Maron: The vaccine is our most effective tool. Try to understand on a one-to-one basis why people are hesitant, as I have said. What is the issue? We certainly do not want staff walking away from the nursing home industry.

Dr Stefanacci: Absolutely. Test for antibodies, as many unvaccinated staff are now safe, having been infected and developed a natural immunity. Provide an alternative such as required masking at all times, no eating or drinking in public or patient areas, and frequent testing.

Can you comment on the concept of mandatory COVID-19 vaccinations for health care staff more generally?

Dr Warner-Maron: If our mandate is intended to provide the highest quality care and services to older people, then how can we do that if 40% of our staff are not vaccinated? It just does not make sense in our industry. In the health care industry, it is absolutely necessary.

I live in Philadelphia. The hospital at the University of Pennsylvania announced a couple months ago mandatory vaccinations by September. Everybody wants to work at Penn for the prestige and the educational support. Mandating it for a hospital, especially that level of a hospital, is very different than doing so for a nursing home.

It is just as important for nursing home staff to get vaccinated, if not more important, because we are taking care of people who are much more vulnerable than the general population.

Dr Stefanacci: Making it mandatory presents challenges. Who is involved in these mandates? Office workers in a nursing home—are they mandated to be vaccinated even though they are not having direct patient care? Are agency CNAs and nurses that we bring in going to be required? If we are short staffed and the only person we can find is somebody who is not vaccinated, what do we do in that situation?

There are hospitals with front-line workers that have not even made it mandatory yet. To make it mandatory and/or restrict funding for not having everyone vaccinated is the wrong direction. We should encourage everybody to be vaccinated, but I think putting mandates in, especially at this time, is likely to have significant adverse outcomes.

Do you have any other thoughts you would like to add?

Dr Warner-Maron: Some states have their own way of looking at this: mandates without any penalties, mandates with penalties, mandates with the threat of penalties. This industry is working on a very small margin, so I think that most nursing homes are trying to address this issue with their staff.

The governor of Connecticut made an announcement that there would be a daily fine of $20,000 for nursing homes unless all staff are vaccinated by September 7. I do not think that fining the nursing home is going to help. I think getting more money to the nursing home so that they can get resources to bring these speakers, these one-on-one interventions, would be much more helpful.

Dr Stefanacci: I think there are softer ways to achieve what we need to. The other thing that very few people are talking about is that there are individuals with natural immunity as a result of being infected and developing antibodies. We are not testing or giving any credit for that.

The other wild part in all of this is if they require a third booster. If we thought we had problems getting people vaccinated before, once we require a third shot, what are those numbers going to look like?

About Dr Warner-Maron

Ilene Warner-Maron, PHD, RN-BC-CWCN, NHA, is an assistant professor at Saint Joseph’s University and president of Alden Geriatric Consultants, Inc. She has had a career in long-term care for over 30 years and has been a licensed nursing home administrator for over 20. She is currently planning a program with the Eastern Pennsylvania Geriatric Society on nursing home policy regarding residents who use cannabis, set to take place in October.

About Dr Stefanacci

Richard Stefanacci, DO, MGH, MBA, AGSF, CMD, is a senior physician at Trinity Health PACE and the chief medical officer of Eversana. He is a practicing internist/geriatrician in the Philadelphia area and an assistant professor at Thomas Jefferson University in the College of Population Health. He spent a year at CMS as a health policy scholar, and his family owns three long-term care facilities, which they are in the process of selling in part due to the growing challenges to operate long-term care facilities. Most of his current clinical practice takes place in long-term care, including a 240-room convent on a university campus that operates as a private pay, combined SNF and assisted living facility.